Abdomen Kidneys

○ Renal cortex has reflectivity that is less than adjacent

GROSS ANATOMY
Overview
• Kidneys are paired, bean-shaped, retroperitoneal organs
○ Function:
– Removal of excess water, salts, and wastes of protein
metabolism from blood
– Regulation of water and electrolyte balance
– Secretion of hormones which control blood pressure,
bone and blood production
Anatomic Relationships
• Located in retroperitoneum, within perirenal space,
surrounded by renal fascia (of Gerota)
• Each adult kidney is ~ 9-14 cm in length, 5 cm in width, 3 cm
in thickness
• Both kidneys lie on quadratus lumborum muscles, lateral to
psoas muscles, between T12-L3
Internal Structures
• Kidneys are hollow centrally with renal sinus occupied by
fat, renal pelvis, calyces, vessels, and nerves
• Renal hilum: concavity where artery enters and vein and
ureter leave renal sinus
• Renal pelvis: Funnel-shaped expansion of upper end of
ureter
○ Receives major calyces (infundibula) (2 or 3), each of
which receives minor calyces (2-4)
• Renal papilla: Pointed apex of renal pyramid of collecting
tubules that excrete urine
○ Each papilla indents a minor calyx
○ 7-10 papilla per kidney
• Renal cortex: Outer part, contains renal corpuscles
(glomeruli, vessels), proximal portions of collecting tubules
and loop of Henle
• Renal medulla: Inner part, contains renal pyramids, distal
parts of collecting tubules, and loops of Henle
• Vessels, nerves, and lymphatics
○ Artery
– Usually 1 for each kidney
– Arise from aorta at about L1-L2 vertebral level
○ Vein
– Usually 1 for each kidney
– Lies in front of renal artery and renal pelvis
○ Nerves
– Autonomic from renal and aorticorenal ganglia and
plexus
○ Lymphatics
– To lumbar (aortic and caval) nodes
IMAGING ANATOMY
Overview
• Well-defined retroperitoneal bean-shaped structures,
which move with respiration
Internal Contents
• Renal capsule
○ Normal kidneys are well-defined due to presence of
renal capsule and are less reflective than surrounding fat
• Renal cortex
liver or spleen
○ If renal cortex brighter than normal liver (hyperechoic),
high suspicion of renal parenchymal disease
• Medullary pyramids
○ Medullary pyramids are less reflective than renal cortex
• Corticomedullary differentiation
○ Margin between cortex and pyramids is usually well-
defined in normal kidneys
○ Margin between cortex and pyramids may be lost in
presence of generalized parenchymal inflammation or
edema
• Renal sinus
○ Echogenic due to the fat that surrounds blood vessels
and collecting systems
○ Outline of renal sinus is variable, from smooth to
irregular
○ Renal sinus fat may increase in obesity, steroid use, and
sinus lipomatosis
○ Renal sinus fat may decrease in cachectic patients and
neonates
○ If sinus echoes are indistinct in noncachectic patient,
tumor infiltration or edema should be considered
• Collecting system (renal pelvis and calyces)
○ Not usually visible in dehydrated patient
○ May be seen as physiological "splitting" of renal sinus
echoes in patients with a full bladder undergoing diuresis
○ Physiological "splitting" of renal sinus echoes is common
in pregnancy
– Causes of dilatation of pelvicalyceal system include
mechanical obstruction by enlarging uterus, hormonal
factors, increased blood flow, and parenchymal
hypertrophy
– May occur as early as 12 weeks into pregnancy
– Seen in up to 75% of right kidneys at 20 weeks into
pregnancy, less common on left side, thought to be
due to cushioning of ureter from gravid uterus by
sigmoid colon
– Obvious dilatation of pelvicalyceal system can be seen
in 2/3 of patients at 36 weeks
– Changes usually resolve within 48 hours after delivery
○ Possible obstruction can be excluded by performing post
micturition images of collecting system and looking for
ureteral jets in the bladder with color Doppler
– AP diameter of renal pelvis in adults should be < 10
mm
• Renal arteries
○ Normal caliber 5-8 mm
○ 2/3 of kidneys are supplied by single renal artery arising
from aorta
○ 1/3 of kidneys are supplied by 2 or more renal arteries
arising from aorta
– Main renal artery may be duplicated
– Accessory renal arteries may arise from aorta superior
or inferior to main renal artery
– Accessory renal arteries may enter kidney either in
hilum or at poles
– Extrahilar accessory renal arteries may arise from
ipsilateral renal artery, ipsilateral iliac artery, aorta, or
retroperitoneal arteries
○ Spectral Doppler

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 Kidneys
– Open systolic window, rapid systolic upstroke
occasionally followed by secondary slower rise to peak
systole with subsequent diastolic delay but persistent
forward flow in diastole
– Continuous diastolic flow is present due to low
resistance in renal vascular bed
– Low resistance flow pattern is also present in
intrarenal branches
– Normal peak systolic velocity (PSV) 75-125 cm/s, not
more than 180 cm/s
□ > 200 cm/s is abnormal
– Resistive index (RI) is (peak systolic velocity - end
diastolic velocity)/peak systolic velocity; normal < 0.7
– Pulsatility index (PI) is (peak systolic velocity - end
diastole velocity)/mean velocity, normal < 1.8
• Renal veins
○ Normal caliber 4-9 mm
○ Formed from tributaries that coalesce at renal hilum
○ Right renal vein is relatively short and drains directly into
IVC
○ Left renal vein receives left adrenal vein from above and
left gonadal vein from below
○ Left renal vein crosses midline between aorta and
superior mesenteric artery
○ Spectral Doppler
– Normal PSV 18-33 cm/s
– Spectral Doppler in right renal vein mirrors pulsatility
in IVC
– Spectral Doppler in left renal vein may show only
slight variability of velocities consequent upon cardiac
and respiratory activity
Size
• Bipolar length is found by rotating transducer around its
vertical axis such that the longest craniocaudal length can
be identified
• Normal size between 10-15 cm
• Volume measurements
○ May be more accurate, but is time consuming
○ 3D ellipsoidal formula can be used for volume estimation
– Length x AP diameter x transverse diameter x 0.5
○ Consistency and changes in volume over time more
important
ANATOMY IMAGING ISSUES
Imaging Recommendations
• Right kidney
○ Liver used as acoustic window
○ Transducer placed in subcostal or intercostal position
○ Varying degree of respiration is useful
○ Raising patient's right side and scanning
laterally/posterolaterally may be useful
• Left kidney
○ More difficult to visualize due to bowel gas from small
bowel and splenic flexure
○ Usually easier to search for left kidney using
posterolateral approach with left side raised
○ Full right lateral decubitus with pillow under right flank
and left arm extended above head may be useful in
difficult cases
Abdomen
– Spleen can be used as acoustic window for imaging
upper pole of left kidney
• Posterior approach for both kidneys
○ Useful for interventional procedures such as renal
biopsy, nephrostomy
○ Use bolster or pillow under the patient's abdomen to
decrease lordosis
○ Image quality may be impaired by thick paraspinal
muscles and ribs shadowing
• Renal arteries
○ Origins best seen from midline anterior approach
○ Right renal artery can usually be followed from origin to
kidney
○ Left renal artery often requires posterolateral coronal
transducer scanning position for visualization
• Renal veins
○ Best seen on transverse scan from anterior approach
○ May also be seen on coronal scan from posterolateral
coronal
Key Concepts
• Accessory renal vessels
○ Accurate diagnosis necessary when planning surgery
(e.g., resection, transplantation)
○ Due to limitations of ultrasound, CT Arteriography,
magnetic resonance angiography or digital subtraction
angiography are more sensitive and accurate
• Normal variants may mimic disease
○ Dromedary hump and hypertrophied column of Bertin
may be mistaken for renal tumors
• Congenital anomalies very common
○ Leading cause of renal failure in children
○ Early diagnosis important
EMBRYOLOGY
Embryologic Events
• Congenital structural anomalies include abnormal renal
number, position, structure and vessels
○ Abnormal number: absence of one or both kidneys;
supernumerary kidney
○ Abnormal position: pelvic kidney, crossed fused renal
ectopia, malrotation, ptosis
○ Abnormal structure:
– Duplication: results from lack of fusion and commonly
produces an enlarged kidney with 2 separate hila and
pelvicalyceal systems, these may join or continue as 2
ureters
□ Ureters may be completely separate until they join
the bladder or join proximal to the bladder
□ "Duplex kidney": Bifid renal pelvis with single ureter
– Hypertrophied column of Bertin (lobar dysmorphism;
Fetal lobulation; Hilar lip
– Pelviureteric junction obstruction
○ Often accompanied by anomalies of other systems
○ VATER acronym: Vertebral, anorectal,
tracheoesophageal, radial ray, renal anomalies
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 Abdomen Kidneys

RENAL FASCIA AND PERIRENAL SPACE

Anterior renal fascia

Lateroconal fascia
Psoas (major) m.

Posterior renal fascia

Quadratus lumborum m. Latissimus dorsi m.

Erector spinae mm.

Liver

Adrenal gland

Anterior renal fascia

Posterior renal fascia

Hepatorenal fossa (Morison
pouch)

Peritoneum

Iliac crest

Transverse colon

(Top) The anterior and posterior layers of the renal fascia envelop the kidneys and adrenals along with the perirenal fat. Medial to the
kidneys, the course of the renal fascia is variable (and controversial). The posterior layer usually fuses with the psoas or quadratus
lumborum fascia. The perirenal spaces do not communicate across the abdominal midline. However, the renal and lateroconal fasciae
are laminated structures that may be distended with fluid collections to form interfascial planes that do communicate across the
midline and also inferiorly to the extraperitoneal pelvis. (Bottom) Sagittal section through the right kidney shows the renal fascia
enveloping the kidney and adrenal gland. Inferiorly, the anterior and posterior renal fasciae come close together at about the level of
the iliac crest. Note the adjacent peritoneal recesses.

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 Kidneys

Abdomen
KIDNEYS IN SITU

Inferior phrenic vessels

Right adrenal v.
Left inferior adrenal vessels

Renal vv.

Left gonadal v.

Right gonadal v.
Superior mesenteric a.

Gonadal aa.

Inferior mesenteric a.

Renal a.

Renal v.

Renal pelvis

Capsule (incised & peeled

back)

(Top) The kidneys are retroperitoneal organs that lie lateral to the psoas, on the quadratus lumborum muscles. The oblique course of
the psoas muscles results in the lower pole of the kidney lying lateral to the upper pole. The right kidney usually lies 1-2 cm lower than
the left, due to inferior displacement by the liver. The adrenal glands lie above and medial to the kidneys, separated by a layer of fat
and connective tissue. The peritoneum covers much of the anterior surface of the kidneys. The right kidney abuts the liver and the
hepatic flexure of the colon and duodenum, while the left kidney is in close contact with the pancreas (tail), spleen, and splenic flexure.
(Bottom) The fibrous capsule is stripped off with difficulty. Subcapsular hematomas do not spread far along the surface of the kidney,
but compress the renal parenchyma, unlike most perirenal collections.

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 Abdomen Kidneys

RENAL ARTERY

Adrenal

Arcuate aa.

Interlobar aa.
Cortical column (of
Bertin)

Interlobular aa.
Inferior adrenal a.

Anterior superior
Superior segmental a. segmental a.

Posterior segmental a.

Anterior inferior
segmental a.
Renal a.

Inferior segmental a.

Renal pyramid

Pelvic & ureteric branches

Renal papilla Renal cortex

The kidney is usually supplied by a single renal artery, the 1st branch of which is the inferior adrenal artery. It then divides into 5
segmental arteries, only 1 of which (the posterior segmental artery) passes dorsal to the renal pelvis. The segmental arteries divide into
the interlobar arteries that lie in the renal sinus fat. Each interlobar artery branches into 4-6 arcuate arteries that follow the convex
outer margin of each renal pyramid. The arcuate arteries give rise to the interlobular arteries that lie within the renal cortex, including
the cortical columns (of Bertin) that invaginate between the renal pyramids. The interlobular arteries supply the afferent arterioles to
the glomeruli. The arterial supply to the kidney is vulnerable, as there are no effective anastomoses between the segmental branches,
each of which supplies a wedge-shaped segment of parenchyma.

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Abdomen
RENAL ARTERY VARIANTS

Aberrant upper polar a.

Aberrant lower polar a.

Splenic v.

Inferior vena cava Superior mesenteric a.

Anterior right renal a. Aorta

Posterior right renal a.

Vertebral body

Aorta

Superior right renal a. with pre-hilar

branching Superior mesenteric a.

Inferior right renal a.

Contrast in renal pelvis

(Top) Graphic depicts supernumerary renal arteries arising directly from the aorta. Some of these enter the kidney at locations other
than the renal hilum, close to the renal poles. These "polar" or "extrahilar" arteries may be ligated or transected unintentionally during
renal or other surgeries. These are sometimes referred to as "accessory" renal arteries, but each is an end artery and the sole arterial
supply to a substantial portion of the renal parenchyma. (Middle) Transverse ultrasound shows 2 right renal arteries running posterior
to the Inferior vena cava. (Bottom) Combined arterial/excretory phase CT in a potential renal donor shows 2 right renal arteries. Their
origins are relatively far apart, which is a factor limiting the sensitivity of ultrasound for multiple renal arteries.

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 Abdomen Kidneys

RENAL VEIN VARIANTS

Supernumerary renal vv.

Right gonadal vessels

Conventional preaortic renal v.

Retroaortic renal v.

Pancreas

IVC
Aorta

Left retroaortic renal v.

Vertebral body

(Top) Persistence of the collar of veins on the right results in supernumerary right renal veins that encircle the renal pelvis. (Middle)
Anomalies of the renal veins are less common than those of the arteries but are encountered in clinical practice and may have
important implications. All anomalies are variations of the embryologic development and persistence of portions of the paired
longitudinal channels, the subcardinal and supracardinal veins, which form a ladder-like collar around the aorta. Normally, only the
anterior components persist, becoming the renal veins, which course anterior to the aorta. Persistence of the whole collar results in a
circumaortic renal vein, which is depicted in this graphic. This anomaly is more common than an isolated retroaortic renal vein.
(Bottom) Transverse oblique ultrasound shows an incidental retroaortic left renal vein.

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 Kidneys

Abdomen
RENAL VEIN VARIANTS

Right renal a.
Left renal a.

Right renal v.

IVC
Left renal v. running posterior to aorta

Left-sided inferior vena cava (empties

into left renal v.)

Right renal a.

Retroperitoneal adenopathy

Right IVC
Left IVC

(Top) The left renal vein is retrocaval. (Middle) Persistence of the left supracardinal vein below the kidney results in a "duplicated"
inferior vena cava. (Bottom) Incidental finding of a duplicated vena cava is shown in a patient with mixed germ cell tumor and
retroperitoneal adenopathy.

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 Abdomen Kidneys

CT UROGRAM

Minor calyces

12th rib

Major calyces
Renal pyramids

Ureter Renal pelvis

Urinary bladder

Right renal pelvis

Low-lying left kidney with

malrotation

(Top) Volumetric multidetector CT can be viewed as a surface-rendered 3D image to simulate an excretory urogram. Postprocessing
includes multiplanar reformation with window leveling, bone subtraction, and arbitrary color maps. Here, opacified urine is displayed as
white. Less dense urine within the renal tubules in the pyramids and the diluted urine within the bladder are displayed as red. The CT
scan was obtained in suspended inspiration, resulting in caudal displacement of the kidneys. In the supine position at quiet breathing,
the upper poles of the kidneys usually lie in front of the 12th ribs. (Bottom) Coronal maximum-intensity projection obtained during a CT
urogram shows a congenital low-lying left kidney. Both kidneys are malrotated with the renal pelves directed anteriorly.

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Abdomen
RIGHT KIDNEY, ANTERIOR ABDOMEN SCAN

Right lobe of liver

Renal vascular pedicle

Psoas m.

Vertebral bodies

Oblique mm.

Right lobe of liver

Medullary pyramid
Renal sinus

Psoas m.

Right lobe of liver

Medullary pyramids

Right psoas m.

Vertebral body

(Top) Longitudinal oblique grayscale ultrasound shows the right kidney using the liver as an acoustic window with the probe angled
medially toward the renal hilum and vascular pedicle. (Middle) Longitudinal grayscale ultrasound shows the right kidney using the liver
as an acoustic window. This approach usually provides excellent visualization of the right kidney and is useful for measuring bipolar
renal length. (Bottom) Longitudinal oblique grayscale ultrasound of the right kidney using the liver as an acoustic window, obtained
with more lateral angulation (when compared with the previous 2 images), cuts through the renal parenchyma on the lateral aspect of
the right kidney. Note that the echogenic sinus is not demonstrated.

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 Abdomen Kidneys

RIGHT KIDNEY, CT CORRELATION

Right lobe of liver

Right hemidiaphragm

Gallbladder

Renal cortex
Renal medullary pyramids

Right lobe of liver

Portal v.

Right kidney with fetal lobulation

Right main renal v.

Perinephric fat

Right psoas m.

Right lobe of liver

Right portal v.
Right hemidiaphragm

Duodenum

Right kidney with fetal lobulations

(Top) Correlative longitudinal CT multiplanar reconstruction of the right kidney is shown. Real-time ultrasound can be performed in any
plane; thin-slice CT is acquired in the axial plane and then reconstructed in other planes. These images have been reconstructed to
mirror the planes used in ultrasound. CT is typically performed with intravenous contrast and acquired at different time points to image
the renal vessels, cortex, medulla, and collecting system. (Middle) Correlative longitudinal oblique CT multiplanar reconstruction of the
right kidney cutting through the right renal vein is shown. The plane of this image is angulated more medially when compared with the
previous image. (Bottom) Correlative longitudinal oblique CT multiplanar reconstruction of the right kidney through the right portal
vein is shown. This plane is angled more laterally when compared with the previous 2 images.

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 Kidneys

Abdomen
RIGHT KIDNEY, ANTERIOR ABDOMEN SCAN

Rectus m.

Right lobe of liver

Duodenum
Gallbladder

Inferior vena cava

Right kidney Aorta

Psoas m.

Rectus m.
Oblique mm.

Right lobe of liver

Bowel
Right renal v.

Right kidney

Subcutaneous fat

Oblique mm.

Rectus m.
Renal sinus
Right kidney

Psoas m.

(Top) Transverse grayscale ultrasound of the upper pole of the right kidney is shown. (Middle) Transverse grayscale ultrasound of the
mid pole of the right kidney shows the renal hilum with the renal vein. Note that the pelvicalyceal system within the renal sinus echoes
is not usually visible unless dilated. (Bottom) Transverse grayscale ultrasound of the lower pole of the right kidney is shown. The renal
parenchymal echogenicity is less than the adjacent liver or spleen. If the renal parenchyma is brighter than normal liver, renal
parenchymal disease should be suspected.

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 Abdomen Kidneys

RIGHT KIDNEY, CT CORRELATION

Pancreas
Hepatic a. Superior mesenteric a.

Right portal v. Aorta

Vertebral body
Inferior vena cava
Spinal canal
Right adrenal

Right kidney

Right lobe of liver

Inferior vena cava
Left renal v.
Right renal v.

Right psoas m.
Right kidney

Inferior vena cava

Superior mesenteric a.

Ascending colon

Right lobe of liver

Aorta

Vertebral body
Right kidney Right psoas m.
Quadratus lumborum

(Top) 1st in a series of 3 correlative transverse CT images shows the right kidney from the upper pole to the lower pole. These are
planes commonly used when performing ultrasound. This image shows the upper pole of the right kidney. (Middle) Transverse CT at the
level of the mid pole of the right kidney shows the renal hilum with the renal vein. The right and left renal veins are opacified, but the
vena cava is not yet opacified. (Bottom) Correlative transverse CT shows the lower pole of the right kidney. The psoas and quadratus
lumborum are variable in thickness depending on patient gender and level of activity.

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 Kidneys

Abdomen
RIGHT KIDNEY, POSTERIOR ABDOMEN SCAN

Subcutaneous fat

Renal cortex

Latissimus dorsi m.
Renal sinus echoes

Renal medullary pyramids

Subcutaneous fat

Quadratus lumborum m.

Renal cortex
Renal v.

Vena cava

Right renal cortex

Quadratus lumborum m.
Renal sinus

(Top) Longitudinal grayscale ultrasound of the right kidney, scanning from the posterior approach, shows normal medullary pyramids.
This approach is useful for intervention, such as renal biopsy or percutaneous nephrostomy, as the kidney is just deep to skin and
muscle. This approach is also a good way for standardizing renal length measurements in children. (Middle) Oblique scan through the
longitudinal axis shows the right kidney with the patient prone. This approach may be problematic due to the presence of ribs. Deep
inspiration may help to bring the kidney down from below the ribs. (Bottom) Longitudinal view shows the lateral right kidney from a
posterior approach.

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 Abdomen Kidneys

RIGHT KIDNEY, POSTERIOR ABDOMEN SCAN

Rib shadowing

Right erector spinae m.

Right psoas m.
Right kidney
Vertebral body

Right erector spinae m.

Right quadratus lumborum Right kidney

Right psoas m.

Vertebral body
Renal hilum

Right erector spinae m.

Right quadratus lumborum

Right psoas m. Subcutaneous fat
Lower pole of right kidney

Vertebral body

(Top) Transverse grayscale ultrasound of the right kidney, scanning from the posterior approach, is shown. Scanning through the
posterior approach is useful while performing interventional procedures, such as nephrostomy or renal biopsy. However,
visualization/image quality may be impaired by thick paraspinal muscles and rib shadowing. This image shows the upper pole of the
right kidney. (Middle) Transverse grayscale ultrasound from the posterior approach shows the mid pole of the right kidney. (Bottom)
Transverse grayscale ultrasound from the posterior approach shows the lower pole of the right kidney.

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